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B-2018-1129 i CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1129 888 BROOKGROVE LN CUPERTINO,CA 95014-4634(375 39 040) MOORE ARCHITECTS PC SUNNYVALE,CA OWNER'S NAME: Jiang Zhenye And Xie Weigao DATE ISSUED:09/11/2018 OWNER'S PHONE:408-800-2568 PHONE NO:(510)812-5688 LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: License Class B Lic.#841906 Contractor MOORE ARCHITECTS PC Date 06/30/2020 X BLDG X ELECT —PLUMB I hereby affirm that I am licensed under the provisions of Chapter 9(commencing X MECH X RESIDENTIAL_COMMERCIAL with Section 7000)of Division 3 of the Business&Professions Code and that my license is in full force and effect. JOB DESCRIPTION: ADDITION FIRST FLOOR(308 SF);BATH REMODEL(2)(110 SF); I hereby affirm under penalty of perjury one of the following two declarations: KITCHEN REMODEL(100 SF);REMODEL OTHER(140 SF);(N)MINI 1. I have and will maintain a certificate of consent to self-insure for Worker's SPLIT SYSTEM(A/C);(N)LIGHTING(17);(N)SKYLIGHTS(2) Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 2. I have and will maintain Worker's Compensation Insurance,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. Sq.Ft Floor Area:308 Valuation:$80000.00 APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type: and state laws relating to building construction,and hereby authorize 375 39 040 R-3(Custom) representatives of this city to enter upon the above mentioned property for inspection purposes. (We)agree to save indemnify and keep harmless the City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION. Signature Date 9-11-2018 Issued by:Kim Dunbar Date:09/11/2018 OWNER-BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS: following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is 1. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for compensation,will do the work,and the structure is not intended or offered for inspection. sale(Sec.7044,Business&Professions Code) 2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant: contractors to construct the project(Sec.7044,Business&Professions Code). Date:9-11-2018 I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER 1. I have and will maintain a Certificate of Consent to self-insure for Worker's Compensation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE 2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6. Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the 3. I certify that in the performance of the work for which this permit is issued,I Health&Satiety Code,Section 25532(a)should I store or handle hazardous shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety CodeSections 25505,25533,and 25534. Labor Code,I must forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent: APPLICANT CERTIFICATION Date:9-11-2018 1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.) to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name to save indemnify and keep harmless the City of Cupertino against liabilities, judgments,costs,and expenses which may accrue against said City in Lender's Address consequence of the granting of this permit. Additionally,the applicant understands and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION Code,Section 9.18. 1 understand my plans shall be used as public records. Licensed Signature Date 9-11-2018 Professional NO F1AOR RECORDING PURSUANT TO GO�IERNIVIENT CODE SECTION 27383 When Recorded MaH Too City of Cupertino Community Development Department 10300 Torre Avenue Cupertino, CA 95014 NO'T'ICE OF SIDEyARD RESTRICTIONS in the Santa Clara County The undersigned, being the owner(s) of the property shown Assessor's Roll ana identified as A.P.N. 375-39-040 and addressed as 888 Erookgrove Lane hereby ,agree(s) that the north elevation (left side) is the conforming side with a setback of 5' and the south elevation (right Iside) is thenon-conforming side with a minimum setback of 5'-1". Any future additions along south elevation (right side) must be setback at least 9'-11" (and/or subject to the discretionary approval of the City of Cupertino) in order to provide a combined side yard setback of 15'-0". This declaration is binding. on successors and assigns of the owner(s). 24126061 Regina A l oormendras Santa Clara County - Clerk -Recorder 03/01/2019 11:58 -AM Titles: I Pages: 3 Fees:10.00 0.00 Taxes: 0 _Total: III 91F.FrIthT IMIK, A IN, NOVO I.4111RIA 11111 PROPERTY OWNER(S)'. Owner's Signature �d Print Owner's Name 31001 ho Date CITY AUTHORIZATION: Erika Poveda, Assistant Planner C AL11 FOo RM11W ALL =PURPOSE ACKNOWLEDGMENT EDGMENT Cl!!lL CODE § .1109 A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document. State of California County of 0'' o` j Tlok Onbefore me, c i CZ i✓L Y�°.✓� c �r c1 �s f9rtAd+u1f 1 Here Insert Name and Title of the Officer Date personally appeared �' Name(s) of Signer(s) who proved to me on the basis of satisfactory evidence to be th perso (s) whose am (s) mare subscribed to the within ' ent and acknowledgedto me thate/ "/they executed the same in hi he their authorize capa (ies), and that by his/o/their ignature on the instrument the er s), or the entity d erso n (s) acted, execute upon behalf o h th p e instrument. �y,ry�B LOOLA T URE11 SAPUOAR y J Notary Public • California a a Santa Clara County m g Y ° Commission ff 2247155 `"L°'"� !�y Comm. �xPires Jun 22, 2022 Place Notary Seal and/or Stamp Above I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature �4Siof Notary Public I�PTIL f��lp.L. Completing this information can deter alteration of the document or fraudulent reattachment of this form to an unintended document. Description of Attached Document ri Title or Type of Document: Document Date: td I� Number of Pages: Signer(s) Other Than Named Above: capacity(les) Claimed by Signer(s) Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑ Guardian of Conservator ❑ Other: Signer is Representing: ©2017 National Notary Association Signer's Name: ❑ Corporate Officer — Title(s): ❑ Partner — ❑ Limited ❑ General ❑ Individual ❑ Attorney in Fact ❑ Trustee ❑-Guardian of Conservator ❑ Other: Signer is Representing: A notary public or other officer completing this certificate verifies only the identity of the individual who signed the document to which this certificate is attached, and not the truthfulness, accuracy, or validity of that document: State of California } County of r Con ct ctarc } ..On ACtrck I z,06 before me, Iwaikeri ' M OA'Aira pI.S bG *i ., , (Here insert name and titiVt the onicer) personally appeared eov "i �, Ild, - °W who proved to me on the basis of satisgctory evidence to be the person(s) whose I names are ubscribed :to the within instrent and acknowledged to me that.. he/she t executed the same in his/her/the authorized capacity(ies), and that by his/he their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. YUNZHEN GAO WITNESS my hand and official seal. _rnia PlotaryPublto -'Califoz ZSAnta Clara County Z `"i��^"` Commission# .1402 MyComm. Expires Decec16, 2022: NotarjPu li Signature (Notary Public Seal) SI ®ISI®V�Ah ®.G��IOlel l= BPIF®Rl�h�l0�l INSTRUCTIONS FOR CONTLETING THIS FORM This form complies ivith current California statutes regarding notary wording and, DESCRIPTION OF THE ATTACHED DOCUMENT if needed," should be completedns iand attached to the docuent. Aclnsowledginents - t fr•oni: other states may. be completed for documents being sent tolhat state so long- as ongas the wordingdoes not require the California notary to violate California notary �1�4��Ira}tP�g'p���63Fj�s Icay. (Title or description of attached document) o State and County information must be the State and County where the document signer(s) personally appeared before the notary public.for acknowledgment. o Date of notarization must be the date that the signer(s) personally appeared which (Title or description of attached document continued) must also be the same date the acknowledgment is completed: o The notary public must print his or her name as it appears within his. or her Number of Pages il Document Date 5/1111 commission followed by comma and then your title (notary public). o Print the nante(s) of document signer(s) who personally appear at the time of notarization. CAPACITY CLAIMED BY THE SIGNER o Indicate the correct singular or plural forms by crossing off incorrect forms (i.e. lne/she/they, is /.are ) or circling the correct forms. Failure to: correctly indicate this ®. Individual :(s) information may lead to rejection of document recording. El Corporate Officer o The notary seal impression must be clear and photographically: reproducible. Impression must not cover text or limes. If seal impression smudges, re -seal if a (Title) sufficient area permits, otherwise complete a different acknowledgment form. Partner(s) o Signature of the notary public must match the signature on file with the office of . O : the county cleric El Attorney -in -Fact o Additional information is not required but could help to ensure this 0 Trustee(s) acknowledgment is not.misused or attached to a different document:: Other Indicate title;or type of attached document, number of pages and date. ❑ e Indicate the capacity claimed by the signer. If the claimed capacity is a corporate officer, indicate the title (i.e. CEO, CFO, Secretary). 2015 Version www.NotaryClasses.com 800-873-9865 o Securely attach this document to the signed document with a staple.